 Good morning and welcome to this morning's meeting. I have apologies from David Torrance. The first item on our agenda is to decide if item 3 is in private, and our members agreed. Our second item today is 2 evidence sessions, which is part of our inquiry into alternative pethwy fromwys PwG. Felly, y first of our sessions on that inquiry. Before we start this morning, we had an informal session last night with Service users and some third sector representatives who attended with some of our members to talk about their experience of alternative pathways. I'd be very grateful if some of the members byddwn yn troi i fod yn ymdilydd o'r ddigonfyrdd. Felly yn y cesenni ar gyfer ei cofnigiddodd, mae'r ffordd yn dweud bod yn cyffran o casion sefydliadau wahanol drwy gan symud o'r cynnig, ond rydyn nhw'n dalych yn dDonald Down. Rydyn oedd yn gwneud i'r cysylltu sy'n dwi'n ddweud dweud rhoi ar gael ei ffordd o'r cyffredinig a'i allu ei gydau i'r gwneud. Hoffa wnrif i ddealltu'r bwysig iawn росias. O boblen i gweithio yr unig? Inni wedi t Og diwyllus i ddealltu'r bwrdd yma yn cyfrifol ni thakfa diwyll uch South David Leith secure ym어주, gan weithio ni chi ei ei wneud真r, lle yn gwyllwch ar gyfer Djisild Erdoedd, rydyn ni'n cymryd, yn ei gyd ar y cyflorydol, ond rhywbeth rym ni'n gweithio'r lleoliad y mae'r ond, ond rhoi gyrfa i ddweud ar yr un o'r prysgwun yw'r cyflaesion, ac yn cyflaesion mewn oherwydd yn cydxinfyrwyr darparol. Rydym ni'n gwybod i'r praticiynau. Rydyn ni'n gweithio'r producer oherwydd oherwydd yma yr un i yr ystod, mae yna'r syniad oherwydd i gyd. Mae gêm yn ein ddechrau mae'n ddefnyddio'r cychwyn i allu cynrygiadau ar gyfer y treffio, ac wrth gwrs, mae cyntaf o gwylleniaeth i gyda'r tuchwysgau, i gael y cyllidenio'r cyfair, i gael y cyfair, oedd gael what pathways or what social prescribing is out there. All of the members did define what social prescribing meant, but it was very new to them. They were experienced barriers when they called the receptionist, for example, when they called the GP practice that the receptionist was the absolute barrier to any progress. That was a couple of the issues. One additional is that some other things came up about why can't we make online appointments, why can't we just get text messages to remind us when there's an appointment, and just joined up computer information data systems as well. Some of it is what we've heard previously in our other social prescribing session that we did in the last Parliament session, so it will be interesting to hear everybody else's thoughts this morning. I'm echoing quite a lot of things that came through in our survey, which of course is available to the public as well. Sue, you were in our session last night. Yes, thanks. I suppose most of the people there didn't have anything particularly positive to say. I think they were all aware of the different healthcare professionals that are out there, but they weren't aware of pathways to perhaps access them. Everything was still coming in through that GP, was still that main and primary point of contact. In terms of signposting to the other healthcare professionals, it was very limited again. It was just quite disappointing to hear the reality of what so many people are facing on the ground, particularly in the number of different sectors, but that alternate pathways, the ones at the self-referral, again, there was no experience of that to anything that was taxpayer-funded services. There was, however, a couple of examples of where they'd found the self-referral to alternative pathways provided by third sector organisations. There's clearly a lot of improvement to do again in terms of social prescribing. I only had one panelist that mentioned the referral again via the GP practice to the active gym sessions in their local authority. In terms of using alternative sources, there's a lot of concerns around people's different skill levels and ability to navigate and find that, but online was a main tool. Again, finding that phone line that would then open the door was helpful, but a lot of it was to third sector organisations or via the GP, which I think it just shows where the bottleneck is and there's still quite a lot of work to do. Like Emma, I suppose that I should also reiterate the level of frustration that many of the people feel about A, getting to see their GP and the receptionist at the door, stopping going further. A lot of the things that other people have said there as well. Self-referral waiting lists and being left in limbo was an issue, feeling as if they hadn't heard anything for quite a long period of time. Not enough information and struggling to access the pathways as well was another issue, too. It really highlighted, especially, people who were already vulnerable, so people who were elderly, perhaps in poverty, who didn't have confidence, who were suffering from depression, et cetera. Lack of knowledge and autism was another thing that came up. Some positives as well, though, on social prescribing, particularly it being really good for people who maybe don't have great connections in the local community and feel a bit isolated and how that had made a massive difference to them. Pharmacies as well, getting some really good services through pharmacies to be able to access urgent medication that actually prevented anambulans having to be sent to, at very, very short notice. A few positives as well. Okay. Thank you, Stephanie. Evelyn, you were there too. Yeah, thanks, convener. I was in the same group as Stephanie and I felt it was a really good session, quite a mixed bag in terms of responses. But I think what I took from it was that people were quite positive that there were alternative pathways, but the big issue was access and how we actually get the message across in terms of how are we going to do that, how are we going to inform people that there are actually these alternative pathways available, so there was much discussion about how we could do that better. Thank you very much, colleagues. Thank you to everyone who joined us last night, it was very informative. For our first panel today, we're going to focus on the patient's perspective of access and primary care and navigating those alternative pathways, so leading very nicely on from the summaries that you've all given. I welcome to the committee Val Castello, patient advisor for citizens advice Scotland, patient advice and support service, Margaret Mackay, chair of the Riverside patient participation group, and Hannah Tweed, senior policy officer of the alliance. The alliance, of course, was very helpful in getting our people to our meeting last night as well, so thank you for that. I'm going to ask three of you to open it up to ask what extent do you think that the public out there, and I suppose that bodies like yourself have been involved in the co-design of primary care services, particularly since the GP contract changed and we do have these different strands of practitioners that are available to the public in GP practices and, of course, everything else that we've been talking about this morning around the other alternative pathways that they might be able to be referred to. Can I maybe go to Val Castello first of all? Good morning. I work for the patient advice and support service and run by Cass in Lanarkshire. I think that the main problem that we find is patients' self-health knowledge, their health literacy. If they don't know what's wrong with them, then they can't possibly self-refer themselves, so they are obviously going back to the GP. That's a major issue for people who are not self-aware of what can be wrong with them and people who have health literacy issues. We also find a main problem is the capacity of the alternative pathways. Do the alternative people, the physiotherapists, the nurse practitioners, all have the capacity to deal with these patients? We found in the patient advice service that the referral time for physio and for these other pathways can be really, really long. If they are in pain, they are going to go back to the GP. That is a problem for our patients. We also find that there is not enough public awareness of the alternative pathways. That really needs to be improved. We are having problems with it. I think that people who access it and use it have good positive things to say about it, but it's getting to that point. We also have the digitally excluded general public who cannot access things online, who do not have access to mobile phones. That is also an issue for them. That is probably the findings that we have from the patient advice service. Good morning. I am Margaret Mackay. I chair the patient participation group for the Riverside practice in Musselborough. This morning, anything that I say is based on the experience of one practice in one local authority area, which is East Lothian. You asked about the extent to which patients had been involved in co-production. I would direct you back to the point at which the new GP contract came into force. Clearly, that was a contract between the Scottish Government and the representatives of GPs in Scotland. The one group of people who were not—it's not so much that they weren't involved because, obviously, a contractual thing that I appreciate is between two parties, but it seems to me that what was not looked at there was the impact of that going to be on the patients and how were patients to understand the rationale for the changes that were taking place. My view, based on our experience in Riverside, which is one of the largest practices in Scotland with 19,000 patients, is that, in the main, getting over to the public that general practice is changing and why it is changing and why it needs to change and what is going to be put in place in order to ensure that healthcare needs are still fully taken account of. I would say that there has been an abysmal failure in that, but there really needed to be a communication plan that was at national local—by local, I mean either health board or local authority area—and then much more, even more at the practice level, there needed to be a co-ordinated story being told. General practice is changing and this is what we are going to do. You will be seeing different people, but you can have confidence in them. That messaging has taken place in some places, but it has been fragmented and it has not been coherent and it has certainly not been integrated with the result that our experience is that most patients, until they come up against an alternative, really do not have any idea about why that is happening. Once they have the experience, for example, I put out a call to find out about people's experience of direct referral to physios and the response back was very positive from patients. However, it is a certain group of patients who are more likely to find their way through the pathways that exist at the moment. In other words, the patients who might say that they are more able to have time to navigate through that. I would like to think that we should take a step back and say that people need to understand why general practice is changing, because I do not think that that is well understood at all. Therefore, you find still that sometimes it is pockets of resistance, sometimes it is just because people are not used to it, questioning why I should see a balanced nurse practitioner, even though she may or he may well be the best person to handle your particular circumstance. However, there is a real need to ensure that services are not fragmented, that somebody somewhere is holding the experience of that patient and the need of that patient, you might say, their history as the patient themselves, but also the key member of the health team that they are linked into. That, of course, up until now has been the general practice. I urge the committee to take that step back and help people to understand the fundamentals of why GP practice is changing. I think that the question of co-production is a really interesting opening one, because I think that at a very basic level, I am not sure how much meaningful understanding of what co-production is we see across the world from people who access services. What I would say is that we have examples where that is being done and done well. I know that I have colleagues who work with a local information service in Scotland, who did a great amount of work to expand to speak to people accessing that service about what they needed out of it for it to work. That is a system, so I should have provided a gloss there. It is a website that helps people to search by postcode of key word what services are available in their area, often from the third sector but not exclusively. That is something that we know has been co-produced and co-designed with people in terms of what works. I also know that colleagues who work within GP practices and deep-end practices across Scotland have also been working on those lines about speaking about what forms of access work for people. However, that is not everywhere. There is real variable practice going on. That also links into Margaret's point about the need to be communication about why things are happening in order for those discussions to be meaningful. If you do not have that basic sort of comprehension of the why and what the alternative proposals are, it is much harder to have those discussions about design. However, we have examples where we have seen that and it works well. It is improving outcomes for people. The bottom line is what everyone is working towards. I will give more detail on those, but I am not sure how much you want to the stage. My colleagues will come in and probably ask for more details. It is interesting because I am nodding along, particularly when Margaret was speaking about how it is communicated. We all see in our areas that it has been communicated well and that it has been a reactive communication to a change and that is quite problematic until people access the service. If they get a good service, they are completely fine about it, but that initial reaction to a change, rather than a proactive information sharing about what is going on, is an issue. One of the things that came up last night and has come up in our survey is about the role of receptionists. On the whole, I am worried that a receptionist is a gatekeeper rather than a facilitator to access healthcare in many cases. I want to go around you all quickly before I hand over to Sandesh Gohani for his questions. What is your hearing from the people that you speak to? I think that that is certainly the perception that we hear. Whether or not that encompasses all experience is another question. We have certainly spoken to a range of people for whom that was their experience and others who had expected that to be the case and were pleasantly surprised by, as you say, those good experiences—a real mixed bag, if I can be that informal. To me, there is a real need for something on the house of care model to be really explicitly signposting and, again, back to that question of communication about the role of the receptionist as a facilitator. Something that, when it is done well, really helps people in a streamlined process. However, that also needs to be followed through by meaningful support for those staff, because that knowledge does not come like that. People need to be supported in order to be able to effectively signpost and link people into the communities. They need to have the resources to do that. There needs to be going back to the waiting list comment. There needs to be sufficient timelines that people feel that they are not just being put off—it may be the right place for them if they are referred to—but, if that means a six or eight-month wait, that is not an effective immediate intervention. Obviously, different receptions will have a range of different skills and attitudes, and what is certainly needed is for there to be some clear platform within any practice about how the receptionist operates. However, I would like to take a step back from the individual receptionist, because our experience in our practice is that the receptionist is almost forced to be the gatekeeper because it is so difficult to get through to the practice. For example, I will give you an illustration. If you call our practice when the lines open at eight o'clock, the first message that you will get is that you are likely to have to wait half an hour in order to get through. Obviously, if that is the first message that you get, the patient's blood pressure will rise. When you get through, the level of contact and communication with the receptionist is almost predetermined because the patients have been hanging on to the phone for so long, and they are told not to go off because you will lose your place in the queue. In a way, it is perhaps a bit unfair to blame the receptionist, because, certainly in our experience, they are forced into this gatekeeping role because it is impossible to get through to the practice in most cases in under half an hour. Sometimes we are blaming the wrong person because the medical care in our practice is highly respected and highly commented on. The access into the practice, I think that most patients would say, is devastatingly poor. Unless one can tackle that issue in a way that the receptionists are put in a very difficult position because they are having to give this message, which I think is unfair on them, unfair on the patients and what needs to be looked at are the mechanisms for getting through the practice. Exactly. It is about the system working for everyone. Thank you. Can I come back to Val Castello? I really agree with what Margaret MacDonald has said. I think that receptionists seem to be in a no-win situation. When people call, they have to take basic information. This is seen by patients as triagin, and they want to know what kind of qualifications the receptionist got to triage their particular health condition. However, there are also confusing procedures that they have got to cope with. Patients get text messages to say that their blood test results are now in and they please make an appointment, and then they cannot make an appointment. They wonder why the text message cannot say that they can have a telephone appointment on Thursday at 10 am. For example, it would just make things so much easier. Instead, patients have to, just as Margaret MacDonald said, only eat a clock every morning to try and make an appointment, and those things are all building a level of distrust and dislike for the receptionists, and I think that they are in a very difficult position. Thank you very much. Sandesh, you've got questions. Thank you, convener. It's pretty quite important. I'm a practicing working GP, and I was actually doing GP on Monday, so that's just yesterday. It's very interesting to hear about receptionists. Without our receptionists, there would be zero access to us, and the abuse that our receptionists get is actually quite distressing to hear when they come and tell me about what some of the people have been saying to them, and I know that it's had a frustration from patients, but there is a level that is unacceptable and often it seems to cross the line. I want to go back to a point that Margaret made. In April 2018, the new GP contract came into effect, and among other things, the contract aimed to reflect the role of GPs and reduce the GP workload to allow GPs to concentrate on those things that only GPs could do to be the expert medical generalist. Do you feel that this shift has been communicated to patients, and do you feel that there are further things, and what are those further things, that we can do to get that communication across to patients? Do you want to direct it to them? To Margaret initially, please. Margaret. I hope that I have made clear that I don't think that that has been satisfactorily communicated to patients. The communication is the first step. The knowledge and understanding is the first step, but the measures that are put in place in order for that objective to be achieved are also important. For example, if I can just illustrate it, there are alternative pathways linked into the practice that I am here, but I am not representing the practice, I am representing the patient's participation group, but if you ring in, whilst you are on hold, you are given the possibility of three different telephone numbers, one is an 013 number, one is an 0162 number, one is an 0300 number, one would not take you to it, it would tell you about the direct access to physio, another would tell you about the CTAQ issues, which are for wound care and advanced phlebotomy, and the third one would be for mental health. You are getting these three different numbers on a message, as you are holding on, and your objective at that point is to get through to the practice. You are also hearing about going to accidents and emergencies—don't do it unless it is urgent or essential—and you are also hearing about NHS 24. Clearly, what has not been done is to take that objective of freeing up the GPs to concentrate on those patients with complex needs or multiple problems, and then to make sure that the alternatives that have been put in place are put in place in a coherent manner. For example, again, all of these different services have different opening times, they have different telephone access numbers. If you are a patient, trying to make sense of all that is extremely difficult. I realise that I am only speaking about one practice in one local authority area, but it is certainly not uncommon in that local authority area. If you are going to have these alternative pathways, there needs to be some coherence about them, some integration, and at least mirrored opening times and access availability. That is certainly not the case. From a patient's point of view, it is confusing, it is frustrating and then it gets people angry, sadly. Would any of our other panellists want to come in? I should have said at the very outset that on the platform that you are logged into, BlueJeans, if you want to add to anything that has been said, you can put an R in the chat box ahead of it and I can come to your valve. I agree with everything that Margaret Harvie has said, but you have the situation if you are ill, if you are poorly, if you are in pain, you are getting all these messages over the telephone and you really just need to speak to someone. That is when the anger starts and that is when the situation occurs where you have the receptionist and the patient having a stand-off and it is not good for anyone, I do not think. I feel that they are in a no-win situation, but they are definitely seen as gatekeepers rather than the gateway to help. Echo the comments that abuse to any staff or indeed any person who is not acceptable, but I think that one of the things some of our community links practitioners, so we have 59 links workers working across Asgen, West Dun, Bartonshire, so not Scotland wide and those are the experiences to which I am speaking, but where people have built up established contacts with people and trust with individuals who access and are supported by the links practitioners, that can sometimes be an alternative route. If people are struggling to get through to other services or the not sure way to turn, if they have a good relationship with the links practitioner, that can be a route for them to be signed, posted by a social prescribing to community services and a range of others, but sometimes that direction is back to the GP if it is or to specific medical professionals. That can be useful for people because they are speaking to someone they know, someone they trust, someone they have built a relationship with over in some cases years. I am not saying that that does not also happen with the sectionist, but it is useful that you have that alternative communication pathway sometimes for mitigating that potential frustration that can lead to situations being described by colleagues here. I want to move us on to talking about alternative health practitioners. Sue, you have questions. Yes, thank the panel for their comments this morning already. It has been really enlightening to have the evidence or the reasons and the justifications explained so concisely and made it quite obvious to us where some of the issues would be. Margaret and Val specifically mentioned about the long waiting times for alternative health practitioners are also undermining the ability to alleviate the pressures on general practice because everything is still funneled in through that and we know that patients are more likely to default to going back to their GP again if they have got to wait too long. What do you think needs to happen if we are really going to make meaningful improvements to the capacity on access and making them more available for alternative health practitioners and their pathways? Val and then Margaret, and if Hannah can. I think that public awareness needs to be improved straight away. Public awareness of the alternative pathways, everyone knows about the pharmacist but they do not know about the other pathways that are available. The older demographic tends to self-care, the younger demographic can look up the computer literate and that does work for them. I think that if there is more awareness of the alternative pathways that would help. However, as I said previously and as we have agreed, the capacity is an issue. Do they have capacity for all the possible alternatives to be used fully? I do not know the answer to that if they have the capacity or not. Are there ways to find out how long you would be waiting if you made a self-referral to physio today? Could you wait that length of time? What should you do in the meantime? Those are all things that need to be looked at. How do they publicise us? How do they let the general public know what they can do in the meantime whereas they are waiting for their appointment? I think that those are things that we need to work on. If that is part of an overall plan, which, as one of your previous committee members mentioned, is about redefining the role of general practitioner, it needs to be clear to people that that is a service to which they have a right, given that they have a particular need. I can only use examples that we are aware of. I hope that you will appreciate that. At the moment, unlike perhaps what I have heard from one of the other members, a direct referral to the physio service in East Lothian would appear to be quite straightforward and relatively short waiting time, not an area of great complaint as yet. However, it is a relatively new service or relatively new method. Obviously, the people who are accessing it in the early stages are what I would call the savvy patients. What will happen as the availability of that service becomes more widely known, more widespread, as it should be, because, if that is what is there for, as an alternative, it needs to be known to everybody, then, of course, the pressure point in relation to waiting time, et cetera, I am assuming, will grow. One of the things that is needed desperately is to ensure that the knowledge of the available alternative service is known to all patients, not just the savvy patients. As a patient participation group, that is one of our major concerns about what is happening at the moment, that the people who do not have access to the practice website or to the VIP are not able to navigate particularly well either because they do not have access to the technology or they do not have the skills or perhaps they do not even have the confidence to self-refer. There needs to be a whole step back. How do we promote that service? How do we make sure that it is available to all patients, not just to those patients who will find their way to the top of the list wherever they are? We have spoken about it, but there is still 10 per cent of people who will not accept an appointment with that alternative health practitioner, even if it was there and they would want that appointment with the GP. Why do you think that that might be? Are there legitimate concerns regarding the availability of alternative health practitioners? We have spoken about communication being consistent, being national, et cetera, but we do not have consistent services, so we cannot have a national message. I am just wondering what your thoughts are on that aspect of things. Margaret, perhaps? I agree that when I am talking about the message, it cannot just be one message. It has to be national, local or health forward level and local practice level in a coherent, co-ordinated way. There is no point at just being one. There has to be a plan to communicate those changes that take account of all those groups being on board and giving the same message out. The experience that we have heard from patients is that when they find a direct experience of an alternative practitioner and that has been a good experience, they are fine. It is about people understanding what an advanced nurse practitioner is, for example, and using terms such as a musculoskeletal specialist. That is a physio to me, certainly, and to most people that I know. Whenever there is any change, it is about looking at how the patient will understand that. Let us try to put that over from the patient's perspective, rather than from the professional's perspective. It is a nonsense if a professional gets upset because they are referred to as an advanced practitioner rather than an advanced practitioner. It is what the patient understands that matters and how they experience it. Thank you for the panel for coming along today. I have a question for Margaret MacDonald. She has mentioned that we need the co-ordinated national local message to the public, and I totally appreciate that that is the case there. What difference does the patient participation group have made in her local area? How effective has it been? What positives can we take out of that to improve the experiences of patients at a wider level? Our patient participation group was established at the end of 2018 when two practices combined. It was seen that there was a need to find a way of a merger between two practices. What were the implications of that for the patients? We carried out two surveys, one at the end of 2018 and one at the end of 2019, where we interviewed 100 patients out of 600 attendees at the flu clinics. Now, 100 out of 600 is a small number in terms of 19,000 patients, but it is quite a good response from 600 attendees. That is pre-COVID-19, by the way, and I suppose that is another point that I want to make. Many of the issues that we are talking about have been exacerbated by the pandemic, but they were there before it. The key messages that came out were to ask patients two questions, what is going well at the practice and what could be improved. Before I have been saying this morning that it remains the case that it is the access. Once they got through and saw the relevant practitioner, whether it was the nurse or the GP, they spoke highly of the service. Getting into the service was the key issue, and that remains the case. To that extent, you might say, what difference has the patient participation group made? All that we can do is keep bringing to the practice the key issue for patients. There are ways that could be improved, and we are happy to be a test bed for you, if there is any change to be made, for example to whether it is opening hours or whether it is the message that is on the telephone system or whatever. I think that patient participation groups, if they are well used as a test bed for changes, can be very useful and effective. If they are not used as a test bed for changes, one would ask, what role do they have? I will check in with my colleague, Paul O'Kane, if you want to come in on this theme. No, we will just move on and maybe I can bring Paul back in later. Emma, you have some questions for our panel. Thank you very much, convener. Good morning to the panel. This inquiry is about alternative pathways to primary care. In the last session, we did an inquiry about social prescribing for physical activity and sport. We are not saying that everybody needs to take up cycling and running, but we know that access to the outdoors can be beneficial. We know that men's sheds can support people. We know that joining walking groups can be helpful as well. I am interested to hear from the panel about what the general attitude of patients or what do you experience that patients' attitudes are towards social prescribing. Anyone who would like to direct that to first of all? Nibby Val Castello, please. Hi there. I think that that is beneficial for a certain group. As my group would call them the savvy group, the group who are aware that self-care works, the group that is aware that social activities can help and alleviate issues, but for the other groups, no, it does not seem to work for them again, down to a lack of public awareness. I know that we have talked about it on a national level, but in a local authority level, if people knew what was available to them, what they could join, what the process would be to join it, it might increase the uptake and reduce the need for the GP, but they are not aware of them. They will always go back to the GP practice, because the view of the GP practice is a gateway to other alternative methods of getting better. I think that that is an interesting link to the social prescribing and specifically exercise, in that I know that when I was speaking to our team of community links practitioners before coming into this session and when writing off reviews, we heard a lot of stories of people who live in the areas of higher socioeconomic decoration within Glasgow and Western Marginshire. By and large, not necessarily I like the term that Margaret Valle has been using around the savvy patients, some are, but many are more limited to digital access, so not within that category, necessarily, if we are categorising. However, because they are working with links practitioners, they are still getting those referrals and seeing the benefits of it, so hearing from people who are seeking support for mental health problems, for example, referred to community groups around allotments, outside mindfulness engagement, different forms of community group and support. I think that, particularly during the pandemic, the outsourced spaces were ones that people were more engaged with and continuing to access. Really saying positive outcomes there, the people are reporting back that they are not wanting to access GP services as often, but that they are getting other people involved. They are seeing better outcomes for themselves and feeling better for themselves—all things that people want. We have been seeing a real increase in people accessing people seeking support from links practitioners, so we saw between 2019 and 2020 that we had a 74 per cent increase in referrals, which is huge, even allowing for the fact that we had staff increase that is still substantial. Again, 60 per cent rise in 2020 to 2021. That is part of the consequence of the word-of-mouth effect, but, in those areas, you are beginning to see people talking about that and going, actually, this word for me, and you see that knock-on effect. That is not something that can happen like that. It is slow, but, as it builds, you get momentum. That links into some of the earlier comments about how things are communicated, that it needs to be embedded with the community as well as having that national message. You need that sustained engagement with specific areas. That is particularly true in population groups, where you may see lower digital literacy, for example, or other factors that might make communication via email around Robins more problematic. However, we have, I say, surprisingly high-reported increase in use of services and outcomes, welcome, but there is a real shift in how people are seeking support. We saw how the pandemic made people engage more in daily walk access to the outdoors. Has there been a shift in knowledge about social prescribing because of the pandemic? We know that people were really isolated, so there was telephone befriending services set up, and that would be seen as a social prescribing that is not about sport, but it is about tackling isolation to support well-being. Has the pandemic led to an increase in knowledge about social prescribing? I assumed that it was not jumped in. I apologise if I stepped over somewhat. I do not have concrete evidence for that, but there is reasonable indicative findings to show that. The fact that we found both our links practitioner of health have been going up, and I use that word specifically, but the number of people accessing Alice, the local information service of Scotland, is seeking those providing services online, mental, and all sorts of different forms of community-based support. I have also gone up, but I think that it is 34 per cent during the pandemic, which I can get the specific stats, but I do not have them off the top of my head. However, it is a noted increase. I think that that probably is linked in, certainly to the fact that people are and were more limited in how they could seek support. What I would say is that, with our links practitioner in particular, I am well aware that they took a real effort to phone around—manually phone around—the people they supported pre-pandemic to make sure that it was not just people who could email to be supported, that they were trying different forms of communication in addition to the sort of generic letters going out. They were picking up the phone and they were making that effort. That has also got to be an important part of engaging people with those alternative forms of support and that sort of wider engagement with what it means to be healthy and be supported. Val, you want to come in? Up in during the pandemic, although I think now that people think that things have gone back to normal, if you like, they tend to have fallen away a bit from that and are going back to their old and trusted method, which is to contact the GP practice. That will always be the way when there is a change. People want to go back the way that needs to be reinforced all the time, the walking groups and things like that. The public knowledge has to be increased. It is still there, still available. There are other methods and I think that that is the main issue. Emma Harper I will go on to my final question about community link workers. When I last looked at the data in March 2021, there were 218 link workers that had been registered or looked at on the Scottish Government's website. It looks like we are on track to have about 323 by March this year. Community link workers are supposed to help direct people to what kind of alternative pathway services social prescribing is out there. How can link workers communication for what is available for people for alternative pathways and social prescribing? How can link workers help to support that? I will go back to Hanna first of all. I know that Margaret wants to come in on your last question. Emma, I will go to Hanna first of all and then I will come to Margaret to pick up on her points. I think that it is really welcome that we are seeing an increase in number of links workers. I would be really interested to know whether we are on track for example. Where is that from? I want to read it. My understanding has been that we are well on the way, but I think that it was sitting at the equivalent of 189.3 full-time links practitioners. There is still room for that expansion to continue. Where links practitioners are working in the area, that is much easier to do. People have got the concept and some word of mouth they have seen as they are advertising. I think that when it is brand new to an area, one of the things that is really important that we found is that it is doing that messaging go out in a range of different forms. I mean that in easy-read, accessible, material, community languages, particularly in areas where you have a large number of the population, English will be an additional language, really making that effort to engage with seldom heard from groups, making sure that they are aware of how to access it, and again using Margaret's Fraser the right to access services. That is really key. Having that as part of a really deliberate part of the introduction of links workers within the practice, there is also a degree to which making sure that the practice is fully aware of and that the local community organisations to which links workers may refer people have those established relationships and expectations. That initial legwork that links practitioners have to do around introducing themselves to people and organisations within the community so that they know what their capacity is. Again, you are not doing that thing of referring when people cannot actually accept new members etc. It can be really part of that effective sort of common strategy. I think that there is also something to me about expanding the provision of CLPs as broadly as possible to really make that not an alternative route, but the norm. This is the way that Scotland delivers a range of different care that we can see people just expecting to seek support from a finance community links practitioner or a community links practitioner, as well as the GP or the nursing practitioner, that this just becomes the norm. That is what I think we need to be working towards. We will have that level of information that we have broken, that barrier that puts so much pressure on the GP system, and then all of the knock-on effects of that. I really put my R up in relation to the question before that most recent one about community link work, because it really was about the range of alternative pathways. One of the things that is really important is how consistent and how permanent are any of those alternatives in relation to the social prescribing that is being talked about. That is one of the difficulties that very often initiatives spring up, either entirely volunteer led, which is great if it can be sustained, or they are set up on a short-term pilot basis. However, if you want to see a major change in something that is profound as the health service that is provided, then it has to be sustained and has to be underpinned. I suppose that one of the things that I have been—I mean, this is not related to patient participation group because we have not discussed this, so I want to make that clear. However, it does seem to me that the role of public health has been so important and so powerful in relation to the pandemic that surely there might be a read-over in how we can use the public health service to demonstrate that all those youngsters who go to football clubs—in our area, there are football teams—are full of young people. If that message that this is also part of keeping you healthy can be linked in with the strategic concern that the committee has, then that would seem to me to perhaps be something beneficial that could come out of what has happened to the pandemic. If public health would encompass referencing all the other ways in which we can keep ourselves healthy or grow healthy and strong, that is just an observation. However, I do not think that we can get away from the fact that, clearly, the GP practices are under incredible strain. Therefore, if there are to be alternatives like what they call c-tax centres where you have to go for wound care or pre-hospital blood tests, those services have to be available at pace and in numbers that can draw the patients satisfactorily away from the GP practice, otherwise it would not work. There is a resource issue there. Those other alternatives are being established, but they are being established without it being clear whether there is a right to them or whether it is just something that, if the local health and care partnership chooses to support it and put the money in that way. There needs to be a drill down about how those alternative pathways are being set up, managed, run, implemented and what we are learning from them. It came as a great surprise to patients in our practice to discover that they did not go to get any wounds dealt with at the GP practice anymore because it was not publicised. That is something that has been pretty basic for generations. You cannot expect patients to happily settle for that if they do not know about it in advance and do not understand why it is happening. Hannah, I want to come back in briefly before I go to Gillian Mackay. Yes, just a quick riff off the back of Margaret's comment about sustainability, which I completely agree with. It needs to be. It is pretty key. One thing that we have found is that because the next practitioner contracts are often relatively short-term, we have seen a relatively high—we know of staff turnover as a direct result, not a dissatisfaction with the work or the support that people are providing communities, but because there are on-one-year contracts and people need stability if they are to pay the bills. There is also a question about how, if we are expanding links practitioner and other alternative pathway routes, that is funded to make sure that that could be something that can really build on those connections that matter so much to the role. Some respondents to the committee's survey expressed a pretty negative view of social prescribing. Some said that social prescribing was not the type of care that they wanted or expected to be offered when seeking help from their GP. One said that they would be insulted if they were directed to those services. Another said that that represented an easy way out for the GP. The benefits of social prescribing are well documented. Does the panel think that negative attitudes towards social prescribing stem from a lack of awareness or a lack of explanation about the benefits? Does there need to be a greater culture shift with regards to what care people can expect from access to access from their GP? I go to Hannah first scene as she is nodding lots. Hannah? The short answer is yes, but to provide more detail on that, that is something that we have definitely heard. We have both heard people who felt short changed to be blunt by being redirected to the links practitioners, I would say in most cases. People did then begin to understand and were supported. I think that the proportion of people who were referred and accessed services of those who sought help from links workers in our area is fairly high. I do not have the stats off my head, but it is 11,000 and something, so it is high. However, there is a culture change needed and there is that real sustained communication needed to expand that, particularly where the concept is new. I think that there is a degree to which that is where support for reception staff is really important, so that they can help people to begin understanding of what it is that people are not just being farmed off. Those are professionals who have really in-depth knowledge of local support networks, but they can also see dual sources of support that people can seek. Support from GPs or professionals about what they are seeking help for—for example, the second highest rate of community links practitioners' support was for obviously related issues. Support for filling out peer assessments or social security is much better to come from a links practitioner than a GP. It is also about splitting where support is needed and communicating clearly where that respective expertise lies. It is not an easy job. There is not a quick fix, but I think that it is a matter of really sustained in-use communication about value. That needs to come from medical professionals as well as links practitioners and other members of the community that it is a group effort to communicate the respective expertise. If any other witnesses want to come in, I will remind you if you do. Please use the chat box just to let me know and I will make sure that I come to you, Gillian. Another concern that I have heard raised by GPs about social prescribing is that it takes much less time to explain a prescription than it does to explain a method of social prescribing, such as a nature prescription. Do we feel that GPs' time is a barrier to patients' understanding and engaging with social prescribing? Is the rationale behind and the benefits of it being properly explained to patients? How can we better raise awareness of GPs who have limited time to do so? I think that the main answer has got to be health literacy. If people do not know what is wrong with them, they cannot self-refer. They cannot use these alternative methods. They must go through the GP practice, whether that is to see a GP, whether it is to see the nurse practitioner. If they do not know and are not aware, that will always be their first port of call. I completely understand that when someone goes to the GP practice and the GP offers an alternative, that is not seen as what a patient would want because they are looking for a tablet that is going to cure everything. That is not always the case. I think that that needs a lot of education, a lot of knowledge and a lot of public awareness for alternative methods now. However, it comes down to health literacy. What do the patients know? How savvy are they about their own health and what could possibly be the method to alleviate their problems? We have a lot of referrals in the CAB from community links workers regarding all the things that Hanna has said. It is a well-known fact that, if you are physically ill, you are emotionally ill, and all the other environmental things come into play to your benefits, your employment, your housing and so on. That all comes through the CAB doors. We are a quick fix, if you like. We are always here, but we are only doing a patch-up job and then moving on to the next thing. It really does come down to health literacy and it comes down to public knowledge and perception. I have a question for Hanna, a quick one, I hope. I am wondering about link workers and whether there are formal qualifications or training that needs to be undergone, or whether there are huge advantages on drawing people from a range of different experiences and skills across the community with connections across the community and who are able to connect really well with patients themselves. I know that, within our links practitioners, we have people coming from backgrounds, and that has been really useful to inform their practice. I know that we have an internal training and communication on-going support for an individual system that, to the better of my knowledge, works well. I am afraid that I do not know what I have not actually asked my colleagues what their opinion is on formal qualification. I am leery of speaking on something about which I do not have information. Apologies for the bluntness, although it is an interesting proposal. I think that, if it was to be taken forward, it would be really valuable to see a range of consultation on what would entail the pros and cons and what the different elements of continued professional development would be as part of that. I refer back to my comment about keeping people in the role and building on that expertise and that it is really important that we do not end up in the same situation. So many colleagues in social care end up where people move away from the professional and good support is lost in part because of additional demands. I am happy to speak to my colleagues and come back to you on that one, if that is useful. If you would like direct input from people working in the bubble, please let me know if that would be of benefit. Thank you, Hannah. I can move on to questions from Evelyn Tweed. Thanks, convener, and good morning, panel, and thanks for your contribution so far. My questions are around digital services and what I am interested in is do you feel that patients have and feel that they have direct control over their health using digital services? How can we improve those services? If anyone else wants to come in, that would be good. Those that are digitally included and know what they are doing can easily navigate through the digital services that are available, but, as you will know, that is not for everyone. And when it is not for everyone, it leaves a vulnerable group who do not know how to do this and are excluded from seeking the help that they need. That might be their point of turning to the GP practice but it might also be their point of not really bothering about their health and trying to make do and trying to just cope with their condition rather than seeking out the help that they need. There definitely is a huge gap there. I think that digital services for younger demographic or those that are more tech savvy will work, but for those that are digitally excluded, there is going to be a gap and that needs to be filled. Margaret McKay wants to come in. Both in the written submission, I think that this is one of the major concerns that as a patient participation group we have. Just to give you an example, at present in our practice, the only way in which you can get a prescription or a prescription is either by doing it online or by going to the pharmacist. There is no consistency in what each pharmacy offers in terms of accessing repeat prescriptions. That is just one very obvious example of a group of patients who are likely to be excluded from a very basic and quite simple service, the repeat prescription service. That is one of our biggest concerns. If you are able to look at the practice website and all the various services that are listed there, even though it can be quite confusing, because they all have different numbers and different opening times, but at least you can work your way through it. If you are not in a position to make that first step, then far from improving health equality, some of those changes are increasing health inequalities. I know that that might seem like a very strong statement to me, but that is something that we do not just believe, we believe that we can evidence. I think that it is something that I would ask the committee to consider really seriously, that if promoting health equality is a fundamental objective, whether it be GPs on the ground or Scottish Government ministers, then the digital divide really must be both taken account of and addressed in order to ensure that the changes that are coming in as a result of the changes in GP practices are not increasing health inequalities. That is our fear. Yes, thanks convener. Obviously we have heard evidence that the public is accessing digital services a lot more and they have been doing so during the pandemic. There have been some comments this morning about a move away from that now, maybe trying to go back to GPs more etc. How are we going to get the message out about alternative pathways doing things slightly differently, digital services? I think that Val had touched on this and I wondered if she had any more thoughts. We had a very good TV campaign for walking and for getting out and getting some fresh air, that has definitely dropped off the radar now. We have a radio campaign going just now, I say we, I do not mean me. We have a radio campaign going just now for GP practices and for the reception staff. That is a very positive message to give out, but all of the services that we offer have to be to the local authority, as well as national authority. In each practice, as you all know, runs completely different from another practice. Some practices are phoned at 8 o'clock in the morning, some other practices are not that. Some practices are phoned between one and three for blood test results. Again, all that information can be found on the website, but some people cannot use the website, so how do we promote that? It has to be in local press, it has to be in local radio, it has to be just out there, so people can see it has to be in posters on the walls in the GP practices. That might be a better use of the message that people get when they phone the GP practice error a list of our services, rather than call this number, call that number, do this, do that. I think that we need to really improve public knowledge of alternatives and how they can find out about their services, because they have changed and we have not changed their message to let them know that they have changed. If I may, I would like to ask from the perspective of mental health support and particularly some of the online mental health support that young people have been accessing during the pandemic and have benefited from and learning from the success of that and continuing that. Have any of you got any experience of where the online services have been something that have worked for particular demographics of people and how we can take that learning from the pandemic and incorporate that into a more long-term strategy for those who want it? I am not saying that it is right for everyone. Anyone would like to come in, just please raise your hand and I will come to you. Val. In advice and support service, we do help people to keep their progress going. If they have been referred to going online to breathe in space or some of the other ones that the GP has prescribed, they quite often will phone the patient at first and say, oh, I do not think that it is working or what will I do when I come to the end of it. Our role is to keep everyone engaged so that they know what they are doing next and we would do that by contacting the GP practice sometimes on their behalf or encouraging them to contact their mental health team to discuss what they are doing next. However, yes, there are some successes, but it comes down to the people who can access those types of services. As Margaret has said, there is a huge gap for those who cannot. The gap widens. The more that we put our services online and the more that the health services are online, it isolates the people who cannot access those services, which is a real shame because we have had anecdotal evidence of them working. But they are not right for everyone. Can I come to Hannah Tweed on that? Yes, I think that there is an interesting challenge here in that I am really curious how intersectional the analysis of the results of online and mental health support services, where they work and where they do not work, and how that information and data is being collected, reflected on and used to inform policy. It is anecdotal, I am not claiming otherwise, but we have certainly heard from some people for whom it has been really welcome, it has been a much more flexible method of accessing services, particularly for a folk for whom going out and about to our appointment is much harder, either for reasons of personal mobility or because of care responsibilities, but we have also heard from individuals who have been directed to them, essentially just because they are directed to online services, not because they are most fit for purpose but because waiting lists are shorter, under the understanding that a specific anecdote of someone who was directed towards online and mental health support services went for that because it was a shorter waiting list and then was informed that, if it did not work after a couple of sessions, it is no problem to go back on the waiting list for in person. That is a route, but in practice that did not happen and they just got discharged and went back to the queue. It is really hard to challenge those systems. I think that there is something about transparency and consistency and making sure that there are options to raise it when people have problems, particularly when we are talking about mental health support, when even just going out and seeking that takes the degree of emotional and cognitive energy that people often have in a very limited stage at that point in their lives because of a whole compound list of reasons. I think that it is really important to drill down to the demographics of where things do not work and why and use that to the countering and developing and to make sure that this is digital choice. I think that it also riffs off one of Margaret's comments about the digital thing can be great but it should not be digital first. It needs to be a digital choice so that people can have that range of access and points of access and we really need to be cautious about both losing good practice that has been developed during the pandemic. We need to keep that and build on it but also make sure that everybody is being heard from. I am also thinking of some of the real practice specifics. For example, we have heard of mental health support services that are offered online in support but only if you could have a quiet ring when no-one could overhear. If you have childcare responsibilities, that is not happening, if I may be so blunt. I think that it is also about looking down to that real level of detail about what it means and how other things can be accommodated to make sure that this suits as many people as possible and where that needs to shift. Thank you. Emma, you wanted to come in. Yes, thanks convener. It is just a quick question. Hannah mentioned Alice earlier and Alice is something that is the local information system for Scotland that is funded by the Scottish Government and it is delivered by the health and social care lines. I would be interested to know what your perceptions of how it is working because it is a digital and online service to direct people to what social prescribing is out there. It would be interesting to hear what the panel's thoughts are about Alice. I am obviously going to be speaking from a position of an organisation that is part of Alice, so I will just own that bias. For part of the population, it is a really excellent resource. Although I offer that with a codisil that it should not and cannot operate in isolation, it must be part of a wider package. However, for those for whom online access suits, I think that it is really good because it is community-based, because organisations offering support services can update their own records and information practices. They can have different forms of communication, so they often detail phone numbers and websites. We know that we have GPs and community links practitioners who use our list as a resource for seeing what is available, so it is not always just about individuals having to access websites themselves. It could be a more flexible approach if the digital access is difficult. We have seen a 34 per cent increase across 2020-21, which indicates increased use, but we have also seen nearly four times the rates of referral to Alice from NHS Inform. I think that there are a lot more people coming via that route and seeking support, which, to me, is welcome, because the more routes people have, the more information that will harm them the better. I see no harm in that, as long as there are alternative routes for those for whom digital access is not safe. We have touched on it throughout this session on health inequalities. I am concerned about the inverse care law. As services are placed under increasing strain, it may become more difficult to access due to growing waiting lists. Practitioners having to see more people with more complex issues in the system becomes more complicated to navigate with people who are expected to self-refer to different services. Is there a risk that the inverse care law will become more entrenched? Those with lower levels of health literacy will become less likely to engage with health services, and how can we mitigate that risk? I think that we have to be aware of when planning and communicating. I think that everyone is going to say about that, but I think that everyone is commenting on it. I think that this is where really targeted and deliberate communication is important, to make sure that the areas where you are aware that fewer people are able to access information are developed consciously. However, that requires quite detailed data analysis. What data is being collected about who accesses different services directly versus via GP referral? How is that being broken up in terms of intersection analysis? Insofar as people are happy to share that information, and people should have access to information that is held about them, etc., GP are compliant. That is a really important bit of work that probably puts an onus of responsibility on public health Scotland or other colleagues within the sector who may not thank me for that. If you do not have that intersection analysis, you are going to miss things. That is where you end up with a very real and serious risk of entrenching existing health inequalities that we know exist, that we know have been exacerbated by the pandemic, and that, bluntly, if they are not responded to, it is going to get worse. That would be inexcusable given the current awareness of the situation. I know that the GP at the deep end report was reflecting upon and about the real need to see the balance between specialist and generalist services reset as part of that access point. Drawing on the expertise of people working within GP deep end factors is a really important part of that as well, because those are the areas with greatest health inequalities that are most likely to be affected. That would also be part of my suggested where the expertise lies and the people accessing those services should be part of that process. I have not seen any other panellists who want to come in. I will double-check that our other panellists do not want to come in off the back of what Gillian Margaret asked. I hope that it has been clear throughout the discussion that that may come from the one local patient participation group. That is probably our most serious concern. My answer to your colleague's question is definitely yes. That is a risk. I could give you a very short illustration of it. I prefer to how the satisfaction level is high in relation to direct referral to physio. I will give you an example that I put in my written submission that a patient refers not to availability at the local health centre with physio, but they are offered an appointment the next day in North Derrick, which is a 32-mile round trip. That patient has access to transport. If they did not have the transport, they would have enough money if necessary to take a taxi or resources to get them there. However, if you are in a position where you are on a basic level of income, or if you have caring responsibilities, or if you have young children at home, how on earth would you make that 32-mile round trip for one of the alternative pathways that is being promoted? I will leave that with you as an example. I emphasise that I see that as the major risk of the fragmentation of primary care services. It is not an argument against other specialists being involved in the care of patients, but it is about how we ensure that there is a real clear co-ordination, clear understanding of the role, and that the services are not infragmented. I want to reiterate everything that everyone has said, but communication is key. Targeted communication is key. Things are beginning to open up now. We need to look at making sure that all third sector organisations know of the alternative pathways and that they are able to cascade this down to their users. There are also carer groups, parent groups and every kind of group. It needs to be a targeted communication and also by local authorities as well as a nationwide communication process. I want to find the final questions from Paul O'Kane. In terms of the evidence, multiple witnesses had commented that the alternative pathways had potential to increase. We have heard quite a bit of that paper through many of the answers, but I want to get a sense of what are the mitigations that we can put in place. I think that we have heard some of that this morning, particularly in terms of digital, although I am still not quite clear on how we ensure that people have the capacity that they would need in order to access digital. That is obviously a bigger question beyond just health, but I do not know if there are any reflections on some of the immediate mitigations that they might be able to put in place. I do not know if I want to start with Val. I am not really sure what the answer is. We offer services in the CAB and we offer services from the patient advice. If they cannot aim those digital services, we will do that for them and with them. However, there is a wider issue and it has to be addressed as a national event so that people can access the services that they need. I think that right now we have a situation where there is an excluded group and that is unfortunate, but more than that it is very tragic because they may need services and they are not able to access them. That is just not right and we have to try to make sure that moving forward is an all-encompassing process. I will not say more about the digital gap, but in terms of alternative pathways, when the alternative routes are being planned, what is absolutely clear to our patient group is that, if services are being removed from where patients normally would expect them to be, i.e. the GP practice, they need to be available within the same walking distance or transport distance that patients would have been used to with their GP practice. For example, if you are taking the wound care service, if that is being removed from the GP practice and it is going to be located in what is called a CTAC centre, it is no good in an area the size of East Lothian having two CTAC centres, one in Haddington and one in Musselburgh. You need to have those alternative provisions within the same striking distance that a patient could have expected with the GP practice, otherwise you are building in an inequality. You are building in inequality because people need to have access to transport or if they have caring responsibilities or young children that make it difficult for them to be away from home for a long period, then, in fact, you are actually in planning that service, you are building in the inequality. If you do not ensure that you look at it from where is the patient sitting, where is the patient living and if I have to go to an alternative place rather than my local practice for those services that are now being transferred into an alternative route, then they need to be at least as readily available and better still even more so. Paul, do you want to follow up on any of that? I think that that was very helpful in terms of Margaret's observation, because public transport is a key part of that in relation to reducing isolation. However, I am interested if anyone has a reflection on the digital element. As we see challenges around things like library services and places where people would normally perhaps access IT if they did not have regular access to that. Obviously, that has been compounded by the pandemic, but we also know that there are challenges in terms of those services being available when they are run by local authorities. Macmillan, for example, offers a cancer service to many libraries, which I think is very helpful and very welcome. However, do we need to see perhaps more engagement between library services and funding for them from the health stream in order to support them as a hub? The Scottish Government already has a contract with the cast for the patient advice and support service. That is what we are, patient advice and support service. Should any patients need access to digital services, they can access that via their patient advice and support service. There is one in every local authority, so the patient advice and support service—usually there is more than one worker or sometimes two in each local authority—can help patients to do that. We are busy. There is no doubt about it. We are very busy, but it is not something that we can help with. We can help, and we do help. We are not capturing everyone that we need to help, but our service is there. It is already up and running. We have local knowledge. We have national knowledge. We have extensive knowledge of the NHS and how it works. We have extensive knowledge of each of our local GP practices. We are here. We are available for use. Please promote the patient advice and support service, because that is what we do. That is what we are here to do. We are about to run out of time, but I will come to Hannah Tweed very quickly for a final comment before we break. What Val said, plus the codice that I would add to any proposals around libraries, all in favour of libraries and community provision, is that recent closures have tended to be centred in areas of higher deprivation with more going back to those conversations about health and equities. If you are going that route, I would strongly recommend targeting specific interventions and focusing in the areas where there is most likely to be need and most likely to be digital exclusion, rather than to ensure that you are countering that. Thank you. Good point to end on. Thank you to the three of you for your very helpful evidence this morning, and you have raised some points that I am sure we will be following up in subsequent panels. We are going to take a break, and we will be back at 10.40 with our next panel. Welcome back. Our second panel today is also contributing to our inquiry into alternative pathways to primary care. We will focus on the perspective of doctors and nurses in GP practices. I want to welcome to our committee joining us online. We have Wendy Panton, the senior nurse of NHS Lanarkshire, a Scottish GP professional nurse lead group. We have Dr Chris Williams, joint chair of the Royal College of General Practitioners in Scotland, and we have Dr Anurag Yadav, the general practitioner from the British Association of Physicians of Indian Origin. Welcome to you all. I am going to hand over to my colleague Sandesh Gauhani to open questions. There is a declaration of interest. I am practicing GP for anyone who did not watch the first session. My question on our first theme is around the new GP contract that came in 2018. The idea of this new contract was to widen services and to allow people to get more without necessarily seeing their GP, and the GP was very much supposed to be the expert general practitioner. But what we found with the contract is that there seems to be huge variability across the country. My question is, has the contract, and especially to Dr Yadav, as I know he is from a more rural community, impeded your ability to work and access for patients? Thanks very much, Dr Anurag Yadav, for giving me a opportunity to talk at this important forum. As you rightly said, I am from one of the rural community GP practice. I am a full-time GP in the medical practice in Haig. I am also in the clinical teaching role in University of Edinburgh, and I have already seen a clinical lecture there. The Scottish general practice has gone through quite a lot of change. I am mostly positive. I would start from when the co-op was initially abolished after the big change, and then the whole GP contract from 2018 had a very good vision to improve the general practice in Scotland. It has the vision of putting more funding into primary care, more collaborative working in the multidisciplinary team. It has the all-positive things that we would want the general practice in Scotland to move forward. However, there are challenges that the biggest one is the delay in the contract and how it has been marred by delays in terms of the target. The initial target from 2018 was to accomplish many things by 2021, but I understand that there have been things beyond everybody's control, like the Covid pandemic that came in and now the target is up to 2023. I understand that there is a bit of lack of planning and lack of staffing, which has been a big hurdle. Even though we have got the services that are very good, they are very promising, but the lack of staffing is a big issue with them, and that is keeping things progressing further. Another important point that I would like to point at this point is that communication to primary care and communication to the general public has not been much. Patient expectation is not being taken care of when the changes have been made. We will definitely want more patient education and more awareness to them to see what changes are coming in primary care, such as changes in signposts and social prescribing. Those are very important things that can only be possible if the public is on board in those things. Those are very important areas that will help to reduce the workload in general practice and help us to see more core group of patients where we need the medical attention more, and that will help us to make our workload more manageable. Again, Covid-19 pandemic has put into forefront some of the inequalities in healthcare. The GP contract has been trying to deal with that, but those things have got still a long way from where we can deal with them. There are inequalities in the attainment and different problems in ethnic minorities. Not only that, you can see the geographic differentiation in terms of how there is achievement in different things in primary care in terms of attainment for different areas. You can see that the chronic diseases are more in a more deprived area, which is not a new thing, but it is more exposed to people who have got economic issues in terms of poverty, low income homelessness. They have been more exposed to people with disability chronic conditions. Disparity is more exposed. Again, a similar thing for social and cultural issues is coming into the forefront, which I think we need more to do. We are moving forward from 28 in contract, but I would probably want some more input to tackle those issues from the point of view of the staffing crisis, which I think is paramount. The social and cultural issues are, again, very important. I want to highlight to you about what Bapio is doing in terms of how Bapio starts an association of physicians of Indian origin. We have got a vision. We have got special expertise in how people are managed in terms of language and cultural barriers and the experience that we would want to partner with the Scottish Government to make this more workable for all the population, especially for the ethnic minority working in Scotland. There is another very important thing that I talked about in staffing. Bapio has got a vision of how to manage the practice load in primary care. In fact, that has already been in work in progress in England, where Bapio has arranged for the primary care. There is a wheel and spoke model where we are talking about a ambulatory care type of project in primary care, where the GPs can refer to an urgent care facility. There will be doctors looking after these patients in terms of getting all the investigation done as a one-stop shop. That will reduce the workload going to the hospital, reduce the workload to the primary care. In terms of work, we have thought about maybe getting doctors from India and getting doctors from abroad who will be trained by Bapio for two years in India, and then they will come here and get trained to part of their training for two years, where they will work for one year in hospital, one year in these primary care settings. That will help to run the primary care, ambulatory care unit type of projects. With that, I would like to conclude my case here. Good morning, Chris Williams. My clinical work is as a GP in Granton on Spay. I am here today as the joint chair of the Royal College of General Practitioners Scotland. RCGP is the professional membership body for GPs in the UK. We support GPs at all stages of their career from medical students considering general practice through training, through qualified years and into retirement. The college has devolved councils in Scotland, Wales and Northern Ireland, and we have approximately 5,000 members here in Scotland. We are also proud to have patient representatives who feed in to help to sense-check what we are thinking and learning. We are not involved in negotiating the contract that came in, but we are obviously heavily interested in seeing those changes improve what is available for our patients. We are obviously interested in conditions in which working in general practice is sustainable. I was struck by a comment this morning by Margaret Mackay about how we are patients to understand. Essentially, we are picking up that there are lots of changes going on at the moment through the contract. In general practice, things are constantly changing anyway. We are constantly adapting to the world outside us, the world around us and the health and social care challenges that are there. However, through the contract, we saw some specific changes. It was just alluded to their attempts to make workload manageable. From the survey responses from the evidence given already today, there are lots of people who try to access general practice for a very wide range of things. Access met, we want to see people be able to have an easy, straightforward route in. Again, from the comments that I heard this morning about, Castello was very right to pick up on the health literacy aspect. Our starting point is that we have lots of people out there across Scotland who do not know what is wrong with them, who have fears, who have concerns, and they want an answer in a time that will allow them to be able to get on with all the other things that are going on in their life. Part of what I would also pick up on in the college's role in the new contract is trying to understand the refocused purpose of the expert medical generalist. Some of what was said earlier today cuts to the heart of that. There are some things that are complex. There are some issues that are difficult for people to raise or who think that others will not be able to understand them except for a GP. That might be a GP that they know and trust, but that might be that they see a GP as bringing a set of skills and an ability to understand difficult problems that are not clear. It gets down to GPs being able to navigate all sorts of territory and not needing a flowchart to be able to understand the complexity and carry risk, but the very real root of some of the issues that we are discussing today is that we do not have a large enough GP workforce. We have known for some years that we do not have a large enough whole-time equivalent workforce and that some of the measures are built in to try and support things. Mixed in in the inquiry, there are elements where we are picking up on new ways of working and we are also trying to understand a bit about how the third sector organisations and assistants can bring in new ways of doing things and new ways for people to understand their health and to do things that are not medicalised. Thank you for that opportunity. My name is Wendy Wendie-Panton and I work for NHS Lanarkshire, but today I am representing the Scottish General Practice Professional Leads Group. There are leads from the majority of the 18 territorial and non-territorial boards and, as I said, we represent all of nurses working in general practice, whether they are GPs, general practice nurses or advanced nurse practitioners. I am not working at present as a GPN. I work as a senior nurse, as I said, but I have almost 20 years' experience of being a practice nurse. I think that the original question was what impact the GP contract has had. Is that correct? I think that it is quite a difficult question to answer bearing in mind what has happened within the last two years with the pandemic and how much of an impact the contract has had. Obviously, I can only speak from a nursing perspective. The GP contract was a contract between the Government and, obviously, GP general practitioners who do employ practice nurses and ANPs working in general practice. As a group, we feel that the idea of a general practitioner, the doctor being the first point of call, is quite an outdated approach and it is not really a reflection on current practice within general practice. GPs and ANPs are highly trained, highly skilled individuals and are often a majority of the time the first point of contact for long-term conditions, which, as you know, is a huge part of general practice. We also felt that perhaps the general public does not have the knowledge that has not been informed about the skill set that the nurses have and perhaps that is something that should be better reflected. Often, when some patients are given an appointment by an advanced nurse practitioner, for example, the anecdotal comments that I have heard from ANPs are that I did not know that I would be seen just by a nurse. It is making the public aware of that, what the skill set is, how those nurses have been trained and the vast experience and expert knowledge that they have. We also thought that perhaps the term alternative does not really demonstrate that professional role of nurses working within general practice, in that nurses working in general practice are essential and not alternative. Alternative, perhaps, could have connotations that it is a lesser experience of care that you are going to get, where, in fact, it is not, it is the complete opposite, where it is certainly going to be at a level working within the scope of practice. Perhaps, to allow clarification, it could state that what the nurse is. There is a different general public as a nurse, where, in fact, we have got different specialities general practice, nurse, ANP, advanced nurse practitioner, district nurse, et cetera. Just to reiterate things that had been said previously, a lack of knowledge and communication of what has happened, that is perhaps no fault of anybody. The past two years and still on-going have been unprecedented. Those changes in terms of what the GP contractor did has done in terms of sea tack, immunisation, urgent care, et cetera. Those things were always going to go ahead, but because of the pandemic, it would perhaps appear to the general public that it is because of the pandemic that the plan was in place prior to that. However, if they did not know that, people could not be expected to have that knowledge. Exciting times ahead, lots of great opportunities are important for nursing within general practice, so thank you. On your point, I have to say that my practice nurses are better than me when it comes to chronic disease management, so they are very skilled members of staff. Dr Williams and Dr Yell have both spoke about a staffing crisis within GP with approximately 800 new GPs coming online by 2027, but the worry is that they will be wiped out when it comes to retirements or change in working practices. To ensure that patients have access to the people that they need to see, along with the fact that our practice nurses need to increase, what can we do to improve recruitment and retention of not just GPs, but of all staff? I start with Dr Williams, if that is okay. There are several things that I would suggest. Firstly, it needs to be a less pressured environment. Some of the digital changes that we have seen have been an attempt to make things less pressured, so the ability to put in electronic consultation requests where somebody can go into a web page and submit a message, often in a structured form to the practice, helps to reduce the number of people who are trying to make telephone calls first thing in the day. Across the team, I think that we need an environment where people have enough time to think, to work with colleagues and to develop the new elements that we have. The new contract has helped to broaden the skill mix that is there ready and waiting in GP surgeries in terms of bringing first contact physiotherapists in. That has been an excellent move. Again, pharmacists add another dimension. We see the skill mix really improve, but, as alluded to earlier, I do not think that patients easily understand that every time that they call, and there is often a learning journey for some of the patients about who is there within the practice and how that is organised. In terms of how our practice teams are able to understand each other and how they are able to describe what they do, it has been limited to some extent. I think that we do not do as well as we can in terms of putting out information on the internet. Again, in rapidly changing times, across Covid, we have seen a lot of changes to how practices are able to communicate out to their population. I absolutely take what has been said earlier that digital tools are not for everyone. Some people absolutely have to use the phone, they cannot, they do not have the appropriate technology or they do not have skills or desire to use some of those things. Again, we need to keep the phone lines open. We need to look at evidence at what some of those things that we are doing and understand are they helping. When we have a system of multiple moving parts, we are trying to get that data, trying to interpret that. That is difficult. A lot of the research that we have round about how those changes have been received comes through telephone interviews of people who have used services or who are part of providing those services. We absolutely need more data to understand what we are doing. We need to understand where the pressure points are, and we need to make sure that there is appropriate resource to support those areas that are under pressure. I do not know if anyone else wants to come in. I should have mentioned at the outset that if our questioner is directed to one person, it does not exclude everyone else. Please use the chat box on the platform to put an R in the chat box and I will come to you. Can I add something else into the mix on top of the line of questioning that Sandesh has put in terms of there is wide national messaging on what the GP contract is and some of the stuff that Wendy has mentioned about the qualifications and the expertise that various different health professionals have. However, there is also that layer of the local information going out about how a practice works and who is in the practice and what they can do. That front-end system of a surgery, as well. You heard earlier, our three panellists all mentioned that perhaps that front-end system often can be added to frustration for people, particularly in terms of putting a cue. In my area, I have had systems from some surgeries where after a certain period of time, the line goes dead. Can I throw that into the mix about how you are saying how locally things can be done better in terms of proactively speaking to patients or changing those front-end systems and what capacity there is there to alleviate any of that frustration and improve knowledge? Maybe Wendy nodding away when I was speaking there. You will not be doing that again, Wendy. I will come to you first and then I will go to Dr Yaddaf. I think that there has to be more communication. He said that there was a national drive about what each particular profession did. I do not think that that was articulated very well for the GPN. I will go back to what they said at the earlier meeting. One of the things that they had for the practice nurse, the GPN, was about injections and dressings, etc. For us, as a group, we felt that that was a very outdated description of a general practice nurse. On getting the knowledge out to the public nationally, there has to be more information locally. The thing is that patients are not attending the GP practices because, obviously, of the pandemic we have had to change our way of working. Prior to that, when patients were seeing the doctor or the practice nurse or the physio or the pharmacist, perhaps there was lots of information in the GP practices and screens, etc. That was a really good way to capture people and we have lost that now. Patients are not getting into the surgery the way that they used to. We cannot just drop in or most practices are not able to drop in now. That is fair enough, but we have lost that way of getting knowledge through. If it was not me that was there, perhaps somebody else was and that message could not get passed through. We definitely have to look at more local ways. We have lost a lot of the local things, the local newspapers, people who are not reading them, etc. That is how to try to think about how best we can get that knowledge out, because not everybody uses Instagram, not everybody uses Facebook. Although there are very good ways of getting information out, it is not for everybody. The more targeted local, whether that is through workplaces, schools, etc. Thank you very much. I totally agree with what Wendy said. The local information for more the front end, as she said, for people to be informed. Having said that, with the pandemic time, with the contract changes, lots of changes have been done more centrally with lots of practice changes. New services have been put in. The biggest thing is the two-way thing. There is importance about the local information given to the local population, because the things and services are slightly different in each practice, how they work and how the things are being met for the patient needs there. There is certainly a lack of communication and how to give information to the public firstly, a broader view as to the new changes happening, in terms of how the ANPs have started work as a clinician in primary care, which has been there in the role, but the role has been enhanced. Those changes have taken place. They would have gradually been happening, but they are suddenly capitalised by the Covid-19 pandemic. The information to the public has not been that intense to start with. There is still a lack of intake from the public in terms of the ANPs and still patients prefer to select the GP. Although I totally agree with Dr Glanley, nurses do a brilliant job. Our ANPs do and see patients are absolutely marvellous. It is a first-time approach when the patients see them. There is initial hesitation. Once they see them, they are confident to build up over time and the service runs smoothly. There is a lack of communication, which is, as I said, we want to cut more national coverage in addition to local coverage, which is important. That adds up to the staff morale. With the lack of staff morale, with a lot of negative media coverage, the lack of resources and the lack of staffing, it has got a knock-on effect on the staffing itself. You find it difficult to recruit other people in the same post because there are less people, but if the morale is less, we get less and less staff. From the PCIP point of view, we have got services where we have got funding to get the physios, but we are not getting it. We have got funding to get pharmacists, but we are not getting them. There is a knock-on effect that goes on. Better funding, better working conditions, more staff morale, and as Chris Paisley talked about improving IT services, it would be a way as well if we can make the IT more efficient and not to struggle with IT. We have different systems in primary care, but we do not talk to each other. If we can make the IT more efficient, it will make the working life more better for people, for the staff. In turn, it will have an impact on patients. The happiest staff will have a positive patient outcome. Wendy Panton wanted to come back in. I am sorry to interrupt, but she was crossed over there. That is an inevitable issue sometimes with doing these hybrid meetings. Wendy, you wanted to come back in on sustainability. Yes, just to pick up on sustainability and how, obviously, we have the crisis of GPs, but also a crisis of GPs. We know that it is a new gene workforce. How do we get young, fresh talent into general practice nursing? Obviously, it is one of the best professions in primary care, and we are really passionate about getting new nurses into general practice nursing. We are not exposed to general practice nursing during our nurse training. It is definitely something that we have to look at to get university placements within general practices. That is all dependent on our GP employers working with us to get GPs to get student nurses and exposing them to that. When a doctor becomes a GP, there is obviously a training programme for them within general practice nursing. There is a GP in course, but the nurse does it, which is excellent, but you are not guaranteed to get a place on that. There is not that kind of structured education programme that we have, and there are lots and lots of people who do nurses that are doing master's level modules, etc., in long-term conditions, and there is not a way to consolidate that into a recognised qualification. Also, there are variations between different practices on payment, so there is not the standard within the NHS that the agenda for change, so it is all dependent on the practice. One person could be doing the exact same job in one GP practice, and another person could be doing the same job, but there are completely different paying conditions, so there is not that uniformed paying condition for your employment, which puts a lot of people off because you are not employed by the NHS, you are employed by the GP, so you have not always got the same terms and conditions. Obviously, you can negotiate that with your employer, but not everybody feels confident in that, especially if you are quite early in your career. That is something that takes time to be able to build up those skills, so there are lots of different things that affect how nurses get into general practice and staying the attrition rate can be quite high as well, because perhaps they are not feeling that they have that support, because everybody is really, really busy. We do not have that time that had, perhaps when I started in general practice, we were always busy, but we seemed to have more time to be able to get a bit more support, in that sense, to have kind of tailed off a wee bit. It is not as an attractive post now that it used to be, but obviously we have to make sure that we are getting the people, the nurses into general practice as well and looking at what that refreshed role is because it is changing. That is really interesting, some of what you just said there, about training in particular. Can I come to my colleague Paul O'Kane for some questions? Thank you, convener, and good morning to the panel. The theme that I am looking to focus on is a patient perspective, and a lot of that has been covered in the answers, which is most helpful. Perhaps I can just drill down a wee bit on what patients have said in our response to our call to views. One of the things that they have highlighted is perhaps some negative perceptions of receptionist teams in GPs. I think that we could all probably relate some of that about people's attitude towards those staff and seeing them very often as gatekeepers or negatively as barriers to seeing their GP, which I think is often wrong. I suppose that I am just trying to get a sense of how we better communicate perhaps the triage pathway that now exists for a lot of practices. I am just thinking that our triage pathway is clearer on emergency medicine perhaps, and they are in general practice. So it just came to understand people's own experience of that, and indeed how we continue to communicate with patients. Anyone you would like to go to Dr Williams first? Maybe Dr Williams to start. Yes. I think that there is a particular dilemma around what we are doing to support our receptionists in some places. We are viewing them as care navigators that we are recognising that we have equipped them with knowledge of the healthcare system that we have tried to give them enough knowledge that they can help to direct somebody who is describing a circumstance or a certain sex set of symptoms to a place where they can get seen very quickly. We are trying to have them do a role where they can find the places of the system that have capacity. As I highlighted earlier, that will not always match the expectations of patients or the patients relatives who are calling in, especially if there is a degree of urgency to the call, and as I highlighted earlier, especially if there is a long wait in them getting through to speaking to a person. That reflects a system that is running hot, where there is activity everywhere. I will suggest that one of the things that might not be immediately intuitive that we need to do is that we need to increase the number of training activities that are there as a team, as GPs, as receptionists, as practised nurses, as pharmacists, as first contact physios, and the wider team beyond that. To be able to do that properly, we need to close our doors to everything but emergencies. That does not need to happen often, but it needs to happen multiple times a year. What we might describe as protected learning time or PLT has been very difficult for us to secure. We know that, in the past, there have been arrangements that have allowed NHS 24 to cover some of the phone lines in an afternoon, for example, where we would not be expecting as many of our patient population to phone in with an urgent query that needs to be dealt with the same day. However, it is only if we are able to close our doors, to stop, to pause, to take a breath, to share our experiences of how the different parts of the system are working that will allow our receptionists to speak to patients and their relatives in the way that is maximally efficient in picking up on their concerns to make sure that they are able to give an appropriate place to go and options where possible. My plea would really be around the development of the team, especially given the new territory that we are into. Paul, do you want to come back in? Yeah, no, thanks for that answer. I think that that was helpful. You mentioned bits of how we create space, as opposed to training, and maybe by diverting people via other pathways in terms of NHS 24 maybe having a bit of a support role. I am keen to just understand maybe the panel's experience of things such as NHS 24. Obviously, people would be directed there more in terms of an alternative to presenting at A&E, but I think that what we have seen over the past few weeks is frustration with some of the accessibility of that, you know, 240,000 calls unanswered in a two-month period. The convener mentions frustration with if it rings out of the GP surgery as well. Just to get a sense of, do we feel that our alternative systems in terms of phone advice are up to par in terms of being able to actually support people? No one has particularly put anything in the chat box that they want to come in on that, Paul, but if you want to, please raise your hand and I will bring you in. Maybe if we hear from Dr Yadav, we will just unmute your microphone. I totally agree with the points that have been made before. I would probably emphasise the receptionists if you think about patient journey in the national health services. This is the first point of contact for them to house whoever, whether it is acute emergency condition or chronic condition. That is where the first impression is the best impression, as we say. The reception is a very important part of our general practice. I totally agree that we need more training and funding in terms of staff, so even when we have been getting signposting training for example recently, but we need more time dedicated so that they can do that. NHS24 has been brilliant. We have had a few sessions in the past. We used to get NHS24 cover for them, but this has gradually been withdrawn. We are finding, as a practice, quite difficult to get training sessions for the practice and for GPs because of the lack of NHS24 cover for the training sessions. All life, as a person in practice, has noticed NHS24 that what they have been doing in terms of patient consultation has been brilliant. Their work has been tremendous. The amount of work and the patient expectation has been dealt with very good. During the normal working day, NHS24 if there is an emergency that has to be dealt with by general practice, it will be duly directed to GP practices for it to be managed further on. Patients usually will contact GP unless it is an emergency and they will contact NHS24. However, I have got all praises for NHS24, the way they work and the management of patients have been great. However, I will probably want some more input in terms of NHS24 cover for training, staff training, especially reception training, more capacity and more communication to the patient. For example, when the latest changes in the vaccination transformation project were made, we had a team number of calls suddenly from patients requesting for vaccination appointments, but they have probably not seen that the new number is now for them to call a different place for these vaccination appointments rather than GP surgery as a point of contact. Information going out to patients would help general practice and even deceptions to manage. Before coming here, I had a discussion with our reception staff as well. All the overwhelming comment that they said to me was that they would probably want to raise something about communication to patients and how things are communicated. At the end of the day, it will help their work life to get better with less demands and stop phone ringing all the time. I will give them just a little point, which I would like to emphasise as well. Dr Yaddaf, I have just got an echo of what he said. I was just thinking there, I wonder if there was any thought-giving about receptionists about a training package for them, almost certain modules that they have to do, courses that they have to do, and forgive me if it is already there. It is not just about signposting, about consultation skills, communication skills and so on, but about the de-escalation of things as well as part of their induction programme. Having that protected time as well, or is it something that they do even before they start their posts or before they go on to the line of resetting. We are all in agreement that perhaps receptionists are not the best term, so whatever term they are using, care navigator, that they have that training in place, communication, de-escalation, signposting and everything that encompasses what their role is going to be. That was just something that I was kind of mindful of. Thank you very much, Wendy. Evelyn Tweed has a follow-up question to Paul's line of questioning. Thanks, convener. It was just to follow up with Dr Williams on the point that he made about training, and he said that it was quite difficult to set aside days to close practices for training, etc. Dr Williams, is this a sort of general thing about training, planning, having that time to sort of look to the future? Do you think that if we do get the communication right on alternative pathways, that GPs will actually have that time? So I'd probably just try and describe some elements of the training for a bit of clarity. So firstly, there's training going on all the time in some practices in that we have foundation year doctors, we have GP specialist trainees, we have medical students, we have a wide range of professions who are there to learn to work, but also to learn. There are, I suppose, the events that I'm talking about are the scheduled closure of non-emergency services for a period of a few hours, typically in the midweek, when we expect there to be a lower number of emergencies to come through. The sort of activities that we are then able to do is to be able to hear presentations about cases that haven't gone well or that have gone well to hear about upcoming changes to services. I suppose, especially when to pick up on the comments that we've had already about whether a GP knows about the type of non-medical intervention that a patient is aware of and wonders why a GP individually might not know about a green initiative or other. Often that's the information that is coming through that we're subjected to, that there are large volumes of information. So how do we understand which services are currently up and running in the area which are coming to a close? Will we need team events to be able to cover the breadth of that and for all the members of the team to be up to speed with the rapidly evolving and changing landscape? There's sometimes a perception that why didn't somebody know about one part of the system? It's because there is so much change and continual change. Unless we can be able to sense check amongst clinical teams and the wider administrative teams who have played into that, then we face difficulty in providing consistent experiences for our patients. Thank you. Dr Yaddaf wants to come back in. Thank you very much. I just wanted to, on the same point that I said previously about communication, there's a very common theme that I've come across in primary care is about how patients feel. There's a general perception of patients about confidentiality with the reception staff that they generally are not confident in sharing the confidential information, although we try to put them to notice votes and try to give information to patients that they're bound by the same confidentiality agreement that everybody is bound in the practice. They are part of a confidential team, but probably that doesn't fill up patients with confidence. Generally, they will see the majority of the professional staff are bound by professional regulations, such as the general medical council regulation or the nursing council regulation. For the reception staff, there is nothing from a patient perspective to regulate a confidentiality statement. However, I probably want more communication and broader sense from the Government for everybody to know that that is a confidentiality issue. You can discuss confidential information with the reception staff. Secondly, I want to share a frustration with the reception staff, which is a knock-on effect from the lack of appointments, a lack of support structure in which to give appointment to a patient lack of places where they can sign post-patients to. That leads to more frustration, and that is probably experienced by reception staff much more than any other staff. Thank you. There are all excellent points. I'm going to move on to talking about social prescribing questions from Gillian Mackay. Thank you, convener, and good morning to the panel. What does the panel say is the main barriers to GPs engaging with social prescribing? Dr Williams, please. I would probably cite time and available capacity as high up there. The other thing that I would highlight is the knowledge of what services are available. As highlighted in the earlier session this morning, there are many sources of support and schemes that are present in a pilot phase or have some funding but who don't continue over time to be able to keep track of those individual schemes and who's administrating who's running what the contact details are. That is difficult. I would highlight that Alice was mentioned earlier on in terms of the local information system for Scotland as being something that is capable of tracking some of those different schemes and making it available to everyone who lives in Scotland and beyond because it's there. It's got a very useful interface. It is searchable, so if information is updated then people can understand what's out there. I think that there's very much an argument for other professionals to be able to help patients navigate some of those structures. Link workers are potentially better able to keep up to date and keep in touch with multiple other organisations that provide different specialist type of support and be able to make sure that that's available to the patients that might not realise that it's there, so if you'd like to match people up to what's available to things that might be useful and of interest. I would pick up in terms of some of the survey responses that there is a range of reactions to a GP suggesting things that aren't a conventional medicine or that aren't what a patient had gone into a consultation thinking was available or thinking what might benefit them. I would highlight how we work. We will often go through a whole range of different things and suggest them to a patient, to the people that are with them. Certain of those options might stick in their memory as either highly suitable or highly unsuitable. It's how we navigate that information landscape. My thoughts are that Alice is a superb resource and is underused. If there was an injection of resource into Alice or an ability to make more people aware that it exists and what it can be used for, my thoughts are that that would be a very helpful step. Picking up on Dr Williams' comments about link workers, I've heard concerns raised that due to limited capacity amongst link workers in the financial stream people are facing due to cost of living, much of link workers' time is actually being taken up helping people to apply for benefits and that they don't have as much time to engage with social prescribing. What are the panel's thoughts on that and do we simply need more link workers or should that part of the role be separated out and allocated to welfare rights advisers in GP's practices, for example? I think that you've raised a good point. A financial adviser could perhaps be a better option. The only thing that I would say for that is that it's another person that the patient's seen. That's the only thing. Perhaps the patient or service user fields are getting passed from pillar to post. However, what is their priority? It's finding out what matters to the patient. That is certainly a good idea. Alice, as Dr Williamson said, is very much underutilised, so that's definitely getting that up and running and making people staff aware of competing priorities for GP's and GPN's, et cetera, when a patient comes in and expects a prescription for something. We are telling them that your diabetes will get better if you do XYZ. Patients are quite resistant to that. It's not all patients. That's not true. Some patients can be quite resistant to that, and for us to prescribe them such a thing can be quite challenging. Dr Williams wants to come back in. It was just to mention the welfare rights assistance and the support that people need to be able to manage their lives and their health and to stop financial problems from becoming health problems. Absolutely, we are supportive of putting that resource in settings where people can reach that. That includes the general practice settings. There is a slight difficulty about how many people we can get into any one building in any one day. Much of the general practice estate is already fully utilised in terms of physical space. Some of the initiatives that we have seen around other digital ways of doing things are also because we are out of physical space. Again, coming back to points that were made this morning, if patients have to travel a large distance to services, will services be underused? We would absolutely want to see general practice in the heart of communities. That includes innovations around welfare advice. I will move on to questions from Emma Harper on signposting, picking up on some of the things that have already been mentioned. Good morning to panel number two. Some of the information has been covered already by Dr Chris Williams. She spoke about the benefits of ALICE, which is a local information service for Scotland. In our briefing papers, the Health Improvement Scotland website has a 10-step guide to care navigation and general practice. It recommends that individual practices collate and maintain their own lists of local service providers. I know that GPs will know their own locations, but is it realistic to expect that GPs would collate and maintain their own databases when there are programmes such as ALICE out there? Also, there is one regionally, like Dumfries and Galloway, which is really accessible with an app. How do you feel about the Health Improvement Scotland recommending that GPs keep their own databases of social prescribing places? Dr Williams? I am generally very fond of health and care improvements Scotland's contributions around about quality improvement and about how we make changes to our systems and evaluate how those changes are working to see what we are doing to see whether that is helping things. There are examples. I had an email this morning about a green scheme that is launching in our area, and I could not find it on ALICE when I jumped on there. There are examples where the different systems are not up-to-date or are not synchronised. I would certainly see ALICE as being a resource that can help practices to keep track of some of those changes to the multiple different organisations that do multiple different things. I am happy with their recommendation. I am going back to looking at that. I have had a look on ALICE myself. I cannot find any men's sheds in Dumfries and Galloway, and I know that we have got them from Strunrar to Lockerbie. There is an issue about it being most up-to-date and accurate. I am just also wondering about what steps can be taken to help to support GP practices to enable effective signposting by using your care navigators or other methods. What is the best way to communicate what is out there for people? I will go back to Dr Williams first, but it is a reminder to others. If you want to contribute, just use the chat box. Dr Williams? In so many ways, general practice does things according to the local connections that we heard earlier about how some patients get their information from the walls of waiting rooms rather than over websites. The practice teams tend to know what ways of getting a message out will be the most useful or will get the message to the people that we are trying to reach. There is so much information out there that is coming from different directions. We get constant stories in the media about some types of treatment that are new or groups that recognise gaps in healthcare systems for groups of patients. We will sometimes have a range of inquiries on one sort of topic based on a story that has been in through the press. Our communication systems need to be very dynamic. How we keep track of that information, again, we need to make the best use of technology. The Alice system is available to cover the wider organisations, including third sector organisations. There is also a job to keep track of the hospital systems that we are referring into about trying to understand how those systems are functioning this week compared to a year ago, which waiting lists are potentially causing our patients' discomfort and difficulty. The range of inquiries that we field on a daily basis about even just the hospital treatment side of things is massive. That is before we get to some of those other organisations that, in some way, are less well-connected to general practice or are less visible to general practice. Ideally, we would like to keep track of all those things, but it is tricky. I just want to emphasise some of the points that have already been said. Social describing is very important, especially when it comes to tackling loneliness, but there are practical issues. I totally agree with the Health Improvement Scotland that GP should maintain a list, but it is quite difficult, as Dr Williams said, for us to maintain the list because many of those services are not formed by GP. They are the third party of voluntary organisations that have got those services. The onus is for them to inform GPs as to what services are there, and we can certainly direct the patient to those relevant services once we get the information. Again, there is a practical point about the trust in some of the services in terms of how efficient they are and what is the capacity of those services. Many times, we end up signposting patients to those services only to find that they have not stopped working unless we have more proper communication about the availability of those services in a more unified way. It will be difficult and challenging tasks for practices to keep on chopping and changing those things and for directing the patients to those services, where even the GPs are not very well informed about how efficient they are and how their working capacity is. I would appreciate some kind of central database of those things where things could be accessed by GP services directly and a more active database could be maintained and GPs can tap into it like there is ProCode Alice today. That would be my point on it. I think that maintaining a database for a GP practice would be a very arduous and difficult task for them to keep it up-to-date. It is another thing that we are asking GP practices to do when we are already at stretching point. I do not think that GPs, nurses, physios etc. can be expected to know absolutely everything that is out there, as much as we would like to be able to maintain all that information. I think that that is really difficult. Therefore, I think that access for practices to clinical link workers is equitable throughout Scotland. The patient does not have to physically see that clinical link worker by having access to them, whether that is through via telephone or whether it is through attend anywhere, etc. That is their role, their job to know those things and they have access to that, so that the patient is not missing out on what is out there, because there is so much out there that is excellent services, but for the practice staff to be able to have that knowledge on their own, I think that that is quite a difficult task to be asked. According to the support in mind report that is in front of me, it says that 25 to 50 per cent of GP appointments focus on non-medical issues such as social isolation, financial struggles and bereavement. I am aware that there is an RCGP training for signposting. Does the RCGP training cover signposting for social isolation and financial issues as well? That would be a question for Dr Yaddaf or Dr Williams. Thank you. Signposting, as you said, convener, is a very important part. RCGP has been doing work on it and we have had the signposting training for the staff, but when it comes to the local things available and what is available locally would be a challenge in terms of GP's to keep it up on what is happening locally. As I said, in terms of the services, sometimes it keeps on changing. Many of these services do not have any say on their working partners. Sometimes they are the issue of funding for them. I have had patients who might refer to services that are working only to come to know once I ask patients to be referred to there as a self-referral. I realise that the services are stopped now in the area. Things fall back on to GP as to manage them back again, which could have been dealt more efficiently if the services have been running or if we have known about the services. It is good to have the services that we would like to have some kind of information from other parties who have established those services to be proactively informing GP about it so that we can keep the note of it and if the services are being stopped, then if we get information about it as well. Thank you. We have had quite a lot of information today. I am just thinking within bearing among what we have heard about the challenges with signposting and the pressures that we are facing right now in terms of the immediate pressures and the medium-term pressures as we come out of the pandemic. What sort of things do you suggest that we look to try and do with solutions to tackle those issues with signposting, with the services changing, the issues with funding and what could be some short-term solutions for us to implement quickly to alleviate the immediate pressures of coming out of the pandemic? Dr Williams, perhaps maybe initially, that is okay? I will just pick up on the previous question, because it was about an RCGP resource. I am quite happy to look into what is covered, especially if there are any areas where the committee thinks that it could be strengthened. I am very happy to go back and see what updating we can do and what rewriting to make sure that it is as contemporaneous as it needs to be. In terms of solutions, I would give one clear solution, and that is the public messaging side of things. It is very difficult for individual patients to understand the whole of what has changed over the past few years. There have been lots of messages going out in terms of the Covid changes, but in the background we have had an agenda of primary care reform that we have been trying in terms of the composition of the team in general practice surgeries to change the skill mix that is there. I think that getting that message out very much we need to counter the narrative about people being bobbed off when the efforts are genuinely to get them to someone who can help them or can start their journey of assistance. In a timely way, we need to be clear that we are trying to avoid harm through people waiting to get a service that might have difficulties with availability or they might be able to see a certain person or a certain role, but it might be quite a wait to get there. I think that there are misunderstandings about what referrals are, for example. For some of the first contact physio therapists, their role is not so much referral but an appointment system to try to get somebody seen within a short space of time so that their health condition can be assessed. That is different from the historical physiotherapist role, where people associate physiotherapy with getting rehabilitation instructions with being given exercises to do. If the first contact physio model is different, an interesting aspect of that is that when you look at those schemes, it is not freeing up general practitioner time in the way that it was envisaged, but it is providing a very quality service to our patients. It is bringing skills into the practice that other members of the team can benefit from. There are strategic elements of that that we need to communicate to the population that we serve, our patients and their relatives. Dr Yaddaf? Thank you very much. I was essentially going to speak on the same things that Dr Williams has already touched upon. My important first day, I would like to say that we need more information to GP practice regarding the resources available. Secondly, more training to the staff in terms of signposting, maybe more funding available for that, more dedicated time could be given, like we said about NHS 24 cover during the time of the training. Thirdly, I would emphasise increased communication to the public, so they have more confidence in the uptake of those services. If those services have an easy way of access for patients to even self-refer, so if the information is out there and the patient is able to self-refer, that will be a further step ahead in terms of signposting. I am going to move on to questions from Evelyn Tweed. My questions are about service design. We often hear from the public that they have not really been involved in the changes to GP services. To what extent has the public been involved in the co-design of primary care services and in what way? How has the general practice workforce been involved also? Possibly to Wendy, and if anyone else wants to come in. I think that we heard clearly from the service users this morning that they did not feel that they had been involved very much. I echo those sentiments. I would also say, from the GPN perspective, that in terms of services that have been transferred from general practice to health and social care partnerships, that perhaps there has not been as much of an involvement of GPNs and other practice staff within that, that they could be using their expert knowledge to help design services. There are a lot of things that perhaps communication would help with and that that can certainly be progressed further in the future as things move on, and involving both service users and other members of staff as well. Thank you. I mean, we go for a GP perspective on this. We go to Dr Yadda first and then to Dr Williams. Thank you very much. I totally agree with what Wendy said, but there has been public involvement to some extent, but we definitely would like more public involvement in terms of the changes that have been happening. There have been lots of changes from, like when we talk about 2018 GP contracts, there have been lots of changes for GPs and lots of new ways of working. I suppose that because there has been lots of changes and there have been some patient involvement, but not to that extent. The information to the public is not there and the services are not very, patients are not very much informed about them. There is information coming gradually, but the speed of information coming to public is at a lower pace than what is actually happening on the ground. We will definitely say that we need more public involvement and patient involvement in further decision making or changes in primary care. I would probably identify that there is lots of feedback that practices get from their patient population. In terms of how consultations might formally occur when there is major service change, I do not think that there has been consultation in the way that would occur if a large hospital was being built—for example, a multimillion-pound endeavour. I would come back to what I said earlier on that general practice is almost in a constant change of state of change. There is a continual flux of how we schedule our appointments, what technologies we are using and what people are part of the team. The 2018 contractual changes have changed some of that. I think that it will be interesting for health boards and for health and social care partnerships to get feedback about how that is working. There is certainly change that is still to come. Although we are waiting for the contract to fully bed in, there are still further steps to be taken beyond that. I might make reference earlier on to the primary care improvement plans that are submitted to try and track where we are in the implementation of that contract, how many different people are employed in terms of physiotherapists, pharmacists and other types of workers. Those things give us some sense of where things are at, but there has been a different pace of change in different board areas and in different health and social care partnerships. There is probably a difficult task in bringing together feedback about that, and I recognise the importance of service design in seeking the views of users. Evelyn, do you want to come back in with any supplementary questions? Thanks, convener. My second question has been covered off by answers already. Thank you very much. It's Stephanie Callaghan. One of the things that has come up is the fact that service design should be informed by evidence. My first question is how can we build a more effective evidence base for improving service design and what lessons do we need to learn to improve the future design of alternative pathways? If I could ask that to Dr Williams first, please, thank you. In terms of evidence, one of the big changes that we are going to be seeing over coming months is being able to understand the system activity in ours in general practice. We have always had data at an individual practice level about how many people are being seen and how appointments are being used, but it's been difficult to get a greater oversight of that. What we don't want to do is extrapolate in ways that don't pick up on what's actually happening. Particularly in terms of where there is activity that's displaced or if we are making changes to one part of the service, what impact do we see on other parts of the service? We now have a technical means in general practice to be able to extract that information from GP clinical systems and to be able to, for the first time in Scotland, get a much higher level, so at a cluster level or at a board level, around what activity is occurring and what's at an individual, on a role-specific level as well, the sort of things that are happening and comparing them across different points of time. Will I bring in... Is there anyone else who wants to come in on that or come back to you, Stephanie, for a follow-up question? I'm not seeing any of our other panellists wanting to come in, so I'll just... If you do, please let us know in the chat box, otherwise Stephanie, on you go. That's fine. If I could just pick up my second question with Wendy, I'm wondering what specific actions should be prioritised to improve service delivery and also should scaling things up be a priority, scaling up successful things to national level. I'm thinking of, for example, there's the case study from Audit Scotland that's in the papers this week where you've got Highland Council introducing primary mental health care workers and the evaluation and outcomes from that showing that 78% of young people and 95% of parents felt that the support had mostly completely helped their situation. Thanks. Wendy. Yeah, definitely. I think that that is something that we absolutely have to do, is evidence and showcase what is happening within primary care, within general practice, though looking at working and involving primary care improvement teams with the PDSA test of change, et cetera, so that would be definitely something that I would be keen to see to be done, because we want to focus on what's the good things that are happening within general practice, within primary care, so definitely. Can you repeat your question again, sorry? What was the first part of the question? The first part was really what specific actions should be prioritised to improve service delivery, and then that second part was should that be one of those priorities? Yeah, absolutely. Mental health would definitely be a priority. It's all down to individual practices and what their priority is. Every practice is going to have different priorities and different needs for their patients, so I think that bringing that kind of local perspective into it with that quality improvement and working quality improvement teams working with general practice, because we know that in general practice there is lots of really good improvement work done, but perhaps not evidence and showcase the way that it could be and should be done, so individual things for individual practices. Thank you. Can I just pick up on that wee bit there as well? See, is there a conflict then as well between the evidence-based approach and also the idea of patient participation in co-production? Is there a problem with them pushing up against each other at times, or how do we get them to integrate and work effectively together? I don't think I can really fully answer that question for you, but my initial thoughts would be no, that there shouldn't be any kind of quality improvement. We want to involve service users to make—how can we evaluate it without having their input and their thoughts into it? My initial reaction would be no, but I would be keen to hear from other people as well to hear what their thoughts are. I don't want to particularly come in on mental health support workers, Dr Williams. Yes, I know that thank you for raising this again, because I don't think that our answers have fully covered the mental health aspects that are out there, and as highlighted, the desire for easy, straightforward access from a primary care setting. I mentioned earlier about how patients and their families might not understand fully how services are organised, but there is a key advantage for me in understanding this primary care mental health worker. The individuals working in the service are deployed through primary care, not being a part of a secondary care organisation. In terms of the priorities and the ability to focus on delivering services in community settings, but on behalf of a community service, and again with the emphasis being on primary care, because often our community mental health teams are attached to secondary care. I also want to mention the evidence base and the conflict between people's experience and the evidence that we are building. I would point out the qualitative research side of things, that at the moment, without clear data on numbers of people going through the system at different points in time and outcomes, the interviews that our researchers do in many different settings—exercise referral schemes, link workers and first contact physios—all the different parts of the system are being assessed by different groups across different parts of the country. I think that the interviews will pick up on sentiment expressed by people who have used the service, as well as the thoughts of people who are developing and delivering the service. We will move on to the final area of questioning about inequalities from Sue Webber. Thanks, convener. With the panel this morning, some of the patient representatives were talking about the health literacy issue. In fact, there might be those who are trying to find the word—the savvy patients—that will be able to direct themselves to the alternative pathways and are more aware of their condition. Those who were not in that position still need to see the GP to get that primary diagnosis. In the process of promoting the more effective use of our alternative pathways, how can everyone's route into primary healthcare be protected and that we do not discriminate against that group that needs to see the GP to try to understand what is going on? I am sure that you will all want to respond to that one, so I am not sure who wants to go first. We will go to Dr Yadda, first of all. Thank you very much for that. It is a very important area. There are lots of work to be done. This is one particular area that has been highlighted since the Covid-19 pandemic, in terms of inequalities in healthcare, inequalities in attainment of good health, inequalities in access to healthcare. That is very different in different subgroups to different people with chronic illnesses, people like people with disability, people who have got learning difficulties, how they access healthcare. It is quite different in people who are of different languages and cultural backgrounds. It has all been highlighted just to give you a crude data. The number of patients who have died of Covid-19, unfortunately, and the people who were dying from other conditions is quite high. If you think the inequalities and the problems because of inequalities are more than four times the mortality that you see in the pandemic in, say, ten years' time. That has been a crude data extrapolated from our local health board when we had the meeting on inequalities. That is a very important area. How to manage that and how to get on top of it is a big challenge. First, again, a very important part of it is communication. Communication to the patient to inform them how they can access language barriers to get more interpreter service used. For different cultural backgrounds to have more cultural awareness to the staff and the public. In terms of how people are able to access the Covid pandemic, we have changed the way that we have been working. There used to be more than 90 per cent face-to-face consultations before. We are still not fully post-pandemic. We are only up to 50 per cent face-to-face consultation. There is still a lot of telephone consultation going on. There is a video consultation going on for the right reason. Some patients want it. Again, some people who have got language barriers are difficult for them to do telephone consultation. It is difficult for them to do video consultation, especially if they are not IT literate, especially the elderly people, to how to make the service accessible to all and to reduce the strain on the service to make it more equitable would be a big challenge. That will be the main thing that I would want to move forward in terms of more access to the service to all and more data to be provided in terms of where the deficiencies are so that we can improve on them. When we talk about the inequality, we have got the patient awareness, I suppose, but then there is also the geographical variation in service that we have. In terms of what extent can equality in the availability of and access to the alternative pathways be ensured? I am thinking more in particular with perhaps some of the rural challenges that we face and the lack of consistency. I was looking at Dr Williams, who was up in Granton, and Wendy may be able to help as well. There are some services where you need a physical person in an actual location. We have learned quite a lot about services that we can provide remotely. I would hammer home that some of those learning points were services that we did not think could be delivered remotely. I will come back to physiotherapy as a service that we think of as being very hands-on and very people in the same room. We know that, through the pandemic, there were some elements of that service that could still be delivered without being in the same physical space. There was a lot that could be done by telephone, but not everything, but there was a lot that could be done by telephone. I absolutely take on board that, especially in sparsely populated rural areas, there are difficulties around the scale of how many physical locations one person would be able to cover when distributed across a sparse population. I will come back to the digital disparity and inclusion issues. If our starting point is that we accept that some people cannot use certain digital services and that some people cannot travel, we should be trying to create capacity around individuals and communities. One of the difficulties that we currently have is how we identify people who have told us that they do not have a smartphone and will never have a smartphone that they cannot use those things. There is a section of our patients who could use some of those things. However, where upskilling would be possible and where doing that would create capacity for the people who cannot travel and who cannot use devices and who are unable to. In terms of how we shift around that capacity and how we make it more likely that people will have locations where there is a healthcare professional of the type that they need to see, part of that is shifting the population that we can upskill. There is a difficulty and clarity in whose responsibility it is to upskill patients and family where that is possible and where it is within touching distance. Also, particularly how we record our systems that were not designed around being able to collect phone numbers or mobile numbers or home numbers, it is difficult to collect information about whether somebody has broadband or whether they have used Zoom before, let alone whether they have tried to do a video consultation with a medical professional. A lot of people are surprised at what they can do when they are given a little bit of support to do that. That does not fully cover the rural difficulties that you describe, but there are ways in which we can use digital working to try to make sure that there are people who, when they need to be available for a rural area that they can be. I guess that one of the things that is picking up on what Dr Williams says is that it is giving people the confidence that they are not getting a lesser service. It is something that has come through this morning as well. I do not know if you have any reflections on that. There are a lot of people out there who have got visions of general practice that are quite outdated in terms of what they might expect to be able to access or who might give them the help or the assistance. I can come back to the idea that there are lots of very positive messages about what we can do for people in this very busy age in which we live. There are ways in which people can access services without having to leave their work for half a day. There are all sorts of changes that are not just trying to shore things up. There are lots of advances that we are making in and amongst things, but getting that message out in the morning session might not be the most exciting news story for people to run. There may well be other public campaigns that need to be funded to tell people about the services that are there for them here and now, not how they might have accessed services in the past. The changes have been so rapid, but we are at a stage where we can describe the consistent experience that we would hope that people can receive. You make a very good point about media coverage and news stories. I come finally to Wendy Panton. I want to pick up a wee bit about the health inequalities. I cannot speak from a rural perspective, but I want to reiterate the fact that I feel that patients have to get the right to choose the way that they want to access the service. The service should wrap around the patient or the service user, not the other way around. Everybody should have access to a fair and equitable service. I am thinking about health literacy, et cetera, or signposting, but that does not necessarily have to be the GP practice. Is there something there that a patient has got some sort of ability to access another human being, whether that is by telephone and not just the patient, their carers, family, et cetera? By giving a not a named person a service that they can link into, if they have got any kind of questions, et cetera, that is signposting, just to make sure that you are to try to make sure that people are getting that fair and equitable service that they deserve. I want to thank all three of you for your time this morning and for everything that you have told us. I thank you again for excellent panels and a lot for us to chew over. On 15 March, the committee will continue to take evidence of part of our inquiry into alternative pathways or, as we maybe should start calling them, pathways. I am looking at Wendy, because she made a very good point at the start of this session, to primary care. That concludes the public part of our meeting today.